Amid the global COVID-19 pandemic, it has been easy to push aside other global health crises. Antimicrobial resistance (AMR) is one of these; it is a global health issue that has been flying under the radar. AMR refers to a process when viruses, fungi, and bacteria develop resistance to drugs that are developed to kill them. This severely hampers our ability to effectively treat diseases caused by microorganisms. As levels of AMR increase within different organisms, the number of untreatable infections arises. Surgeries and procedures that are considered routine today become high-risk as they are increasingly untreatable.

Antimicrobial resistance occurs when microorganisms are exposed to an antibiotic or drug and develop resistance to it. One of the primary causes of AMR involves the overuse of drugs like antibiotics. Repeated exposure to such drugs acts as a selective pressure. If a random mutation in the genetic code of such a microorganism occurs and confers drug resistance, this microorganism will be favoured above others and will have the opportunity to replicate and form a new strain. Random mutations occur all the time and—given the sheer scale of the rate at which some of these microscopic microorganisms replicate—can lead to the formation of drug-resistant strains. Resistance traits can then also be transferred and ‘shared’ between bacteria by a mechanism known as ‘conjugation.’

It is important to realize that AMR is not just a threat looming in the distant horizon but an immediate threat to global public health. The World Health Organization (WHO) estimates that at least 700,000 people are dying every year by diseases caused by drug-resistant microorganisms. Their projections for the future paint an even more devastating picture; it is predicted that we will be looking at 10 million deaths per year by 2050 if appropriate steps are not taken to combat AMR.

The overuse of antimicrobial drugs—and specifically antibiotics—has been a problem throughout the world for decades. It is only in recent years that people around the world have begun to take action.

However, the response to AMR has been fractured by differences between healthcare systems, political situations, and economic levels of each country with the zones of war and conflict being especially susceptible to antimicrobial resistance. An article by the React Group indicates that some form of AMR has been reported in all recent conflict zones; countries including Afghanistan, Yemen, Syria, Iraq, and Palestinian territories. Research and analysis carried out in 2018 by Médecins Sans Frontières (MSF) suggested that 70% of patients at their Trauma Centre in Aden had antibiotic-resistant bacteria present in their systems. Another MSF report on patients (in a post-operative care facility in East Mosul in Iraq) similarly indicated high levels of antimicrobial resistance. It was reported that between April and mid-November 2018, 40% of patients had a microbiologically confirmed infection, and that 90% of these patients had what is known as multidrug-resistant infections. These figures strongly outline the severity of AMR in war-torn countries—another devastating consequence of war and conflict that adds to the vulnerability of the people in these regions.

There are several reasons why there is an increasing development of AMR in war-torn countries. First, the conflict most often leads to widespread disruption in healthcare systems and services. Healthcare professionals are often the first group of people to leave the country in the face of violence and conflict. Infrastructure is disrupted, and in some cases, medical centres and workers are the primary targets in war. The facilitation of proper procedures for antimicrobial drug and antibiotic use is often not possible. This leads to many critical errors in the administration of drugs and antibiotics. Patients are administered the wrong drugs and antibiotics, incorrect doses, undergo incomplete courses of the treatment, or use unregulated drugs. All these factors combined significantly increase the risk of AMR.

A paper entitled ‘Antimicrobial resistance in the context of the Syrian conflict: Drivers before and after the onset of conflict and key recommendations’ published in the International Journal of Infectious Disease, highlights the issues outlined above—specifically in the Syrian context. The paper describes the troubling disruption to health services, especially in its overcrowded and unhygienic conditions. It identifies it as an issue in non-governmental controlled areas and concludes that it encourages the spread of AMR strains and affects the general health of the population.

In addition to widespread disruption to healthcare services, the types of wounds and injuries that are prevalent in war situations necessitate the high use of antibiotics. Antibiotics are used to treat bacterial infection, and the wounds from bombs, shrapnel, and bullets are often highly contaminated, increasing the risk of infection amongst its victims. In an area that lacks adequate hygiene facilities, the risk is even higher, and the need for antibiotics more critical.

The displacement of populations caused by war and conflict also drives the rise of AMR. Refugee camps are often overcrowded and unhygienic, creating an environment that enables higher transmission of AMR strains between individuals. The paper referenced earlier, singles out Gaziantep, a Turkish city located 50km from the Syrian border, as a particular risk area with regards to antimicrobial resistance. Not only is it home to a large number of refugees, but it is also a site of international medical tourism. This creates further opportunities for the dangerous spread of AMR strains to vulnerable populations.

Another paper published in One Health entitled ‘Antimicrobial resistance in a war-torn country: Lessons learned in the Eastern Democratic Republic of the Congo’ describes the impacts that displacement has had on the spread of AMR in the Eastern DRC. The authors identify both the lack of healthcare infrastructure and the environmental context of re-settlers as a factor to the spread of AMR. They suggest that interactions with the environment provide routes of transmission and spread of antimicrobial resistance strains. The destruction and invasion of land by displaced people could therefore lead to the further spread of strains.

To reduce the development of AMR and to slow the spread of resistant strains, immediate action is needed. Surveillance is a common theme that appears in recommendations for plans and strategies to tackle the issue. To understand and prevent AMR, it is critical to identify and trace existing resistant strains in human disease. To prevent it further, it is imperative to minimize the use of antimicrobial drugs where possible and ensure correct prescriptions and uses of antimicrobials take place.

While these are relatively straightforward measures, they are difficult to implement in war-torn countries. International aid organizations will play a pivotal role in supporting countries in these areas, but sadly, while conflict and war are occurring, it will be difficult to resolve the issues surrounding AMR in these regions.

Whilst the world grapples with the increasing rise of antimicrobial resistance, the scientific community has been scrambling to find a solution. One of these efforts is a project called ‘Phages for Global Health’ whose mission is “to bring phage expertise to the developing world.” Their project focused on the research of bacteriophages—or phages for short— which are viruses that infect and kill bacteria as an alternative to antibiotics. ‘Phages for Global Health’ aims to train and educate healthcare professionals in the developing world so that they can use phage therapies to control outbreaks as well as decontaminate foods. Projects like ‘Phages for Global Health’ provide hope in the otherwise bleak future of AMR and its consequences on global health.